Select group of patients don't need a new kidney

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

More than 63,000 pancreas transplant surgeries have been performed worldwide. Just 8% of those were pancreas only. The rest were combined kidney and pancreas transplants.

Upstate's transplant surgery chief, Dr. Reza Saidi, explores the outcomes of pancreas transplants in a paper published in the World Journal of Surgery, and he's here to talk about it. Welcome back to "The Informed Patient," Dr. Saidi.

Reza Saidi, MD: Thanks, Amber. Glad to be here.

Host Amber Smith: Now, your paper looked at pancreas-only transplants between 2001 and 2020. What did you find?

Reza Saidi, MD: I think this is an interesting topic because the first pancreas transplant was done in the United States in 1964, and they did it for a wide variety of indications. As you pointed out, the majority of them are done for the patients who already have kidney disease and have diabetes, and they receive combined kidney, or pancreas after kidney, transplantation.

But a minority of patients with diabetes, with a very difficult time to manage their diabetes, or they get a lot of hypoglycemia, that means their blood sugar goes way down and can actually cause serious damage to patients, sometimes cause seizures, arrest or coma, and sometimes can be fatal.

And for those patients, a minority of patients, I think pancreas transplant can be an option. In the past, I think there were some papers that showed these patients actually don't do very well because pancreas transplant is a big operation.

But in this paper we look at outcomes of patients who receive pancreas transplant alone. This is only patients who have diabetes, that only for that indication have pancreas transplant. We've shown in the past 10 years actually, despite the fact that the number of these cases have gone down in the U.S. compared to the previous decade, the outcome has significantly improved. And these patients now, it seems that they do much, much better. And we passed the learning curve; we know how to do it. Even a selective group of patients, even with Type 2 diabetes, we can perform this operation. In the past, this was only just for the patient with Type 1 diabetes, but now with the experience that we gained doing pancreas transplant with the patient with Type 2 diabetes, it seems that this patient also might be a candidate.

But again, remember this is very selective for patients that the modern managing of diabetes failed, and they might be a candidate for pancreas transplantation.

Host Amber Smith: So the majority of the patients who receive a pancreas transplant are diabetics?

Reza Saidi, MD: Yes. I would say all of them are diabetic, but most of them have kidney disease, and on top of that they have diabetes, and they receive combined kidney and pancreas transplant.

But a minority of patients who just have diabetes, and it's very difficult to manage their diabetes, or they get a lot of hypoglycemia, might be a candidate for pancreas transplant alone, and our paper showed that their outcome has improved. And this is a valuable option for a minority of patients with diabetes that have a difficult time to manage their diabetes.

Host Amber Smith: So what are the survival rates like?

Reza Saidi, MD: In the past was in the 40% and 50% (range), but now it's close to 70%, which is very comparable to the patients who receive combined kidney/pancreas transplant or just receive a kidney transplant. And again, these are the patients who have difficulty to manage their diabetes.

And I think the survival of 70%, that's a pancreas allograft survival (the transplanted pancreas itself). The patient survival is very close to 100%.

Host Amber Smith: Now, the United Network for Organ Sharing reports that in addition to 97 kidney transplants in 2022 at Upstate, surgeons performed 22 kidney and pancreas transplants, and four pancreas-only transplants.

Does that sound right?

Reza Saidi, MD: That's correct.

Host Amber Smith: Can you go over again why someone would need both a kidney and a pancreas versus why someone would need only a pancreas?

Reza Saidi, MD: Patients who have kidney disease, chronic kidney disease, and have diabetes, they have shown that the best option for them is to have a combined kidney and pancreas transplant because, No. 1, with the combined kidney and pancreas transplant, you cure the kidney disease, and then you cure their diabetes, and because you cure their diabetes, they actually live longer, and they have much better quality of life.

But some people, as I said, a minority of people don't have kidney disease, but they have a very difficult time to manage their diabetes. Then these patients might be a candidate for just pancreas transplant alone. And data that we presented, that paper, clearly showed that afterward, those patients significantly improved in the past 10 years.

And this is a valuable option again for a minority of patients who have a difficult time to manage their diabetes.

Host Amber Smith: So for a patient who only has diabetes, and their kidneys are healthy, there would be no need to also do a kidney transplant.

Reza Saidi, MD: No. Pancreas transplant alone is only for the patients who just have diabetes, no kidney disease, but again, for a wide variety of reasons, they cannot manage their diabetes effectively, or they're getting a lot of hypoglycemia.

Host Amber Smith: So why aren't more people with Type 2 diabetes candidates for pancreas transplants?

Reza Saidi, MD: I think that's a very good point. So, as I said, in the past, people thought that this is a morbid operation with a lot of complications, and it is not worth it to do with this.

But now we learn from our experience, and we are getting better and better with our surgical technique, immunosuppression management, and also postoperative care, with ICU (intensive care unit) care. It seems that more and more this patient might be a candidate, and we learn in a selected group of patients.

Again, selection is a key in this area. You have to be very diligent who's a candidate for this operation. We can offer this operation for patients with Type 1 or maybe Type 2 diabetes.

And then let's point it out: The majority of patients with Type 2 diabetes are obese and old. They're not really candidates. For the patient who are relatively younger and not very obese, I think this might be a valuable option if they fail other, alternative treatment, such as insulin therapy.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Reza Saidi. He's the chief of transplant surgery at Upstate, and we're talking about pancreas transplants for people with diabetes.

Are there a growing number of transplant centers that are offering pancreas-only transplants to people with diabetes?

Reza Saidi, MD: Actually, unfortunately not. Because this is highly complex surgery, and because in the past, the outcome was not good, the majority of programs actually try to stay away from it.

A very few programs actually offer these options for the patient. For example, in, I would say, Upstate New York, we are the main program in offering these. Other programs actually not offering this treatment. But I think for a minority of patients, with the highly selective group of patients, that might be a viable option.

For example, recently we had a patient that we transplanted just the pancreas alone. This patient actually has a lot of hypoglycemia and has a couple of car accidents, and his driving license was revoked and has a poor quality of life, cannot get a job. And with this operation, he's back to a normal life of a good quality, and basically he's very happy.

Host Amber Smith: And when you talk about being selective in the patients, you're trying to choose a patient who the operation is going to be able to help.

Reza Saidi, MD: Absolutely, yes.

Host Amber Smith: So there are some things that might disqualify them. You mentioned obesity, right?

Reza Saidi, MD: Yeah. Morbid obesity, or if they have significant heart disease or have significant peripheral vascular (blood vessel) disease.

These are all a contraindication to proceed with a pancreas transplant.

As I said, selection is a key in this business, and you have to make sure you select the right patients for this operation.

Host Amber Smith: I wanted to ask you to walk us through how a pancreas-only transplant is done. Is this an organ transplant, or do you just transplant islets (pancreas cells involved with insulin production) from the donor pancreas?

Reza Saidi, MD: I'm talking about the whole-pancreas transplant. Islet transplant has also been done in the past, but unfortunately is still considered experimental because the long-term result is not comparable to whole-pancreas transplant. When I'm talking about pancreas transplant, I'm talking about the surgical procedure to transplant the whole pancreas in the patient.

Host Amber Smith: So in that respect, is it like a kidney transplant? You're taking an organ from a donor and putting it into the recipient?

Reza Saidi, MD: Yes, it's pretty much very similar to the kidney transplant. And I think the way we do it at Upstate, we do it very similar to a kidney transplant, and we do not touch the patient's own pancreas. That's going to stay in place.

Host Amber Smith: So the old pancreas remains?

Reza Saidi, MD: Yes.

The pancreas does a wide variety of functions. Some of the function has to do with food digestion. And the reason we do pancreas transplant is just because this pancreas can produce insulin, and the patient's own pancreas cannot do that.

Host Amber Smith: How soon after the operation does the new pancreas begin functioning?

Reza Saidi, MD: I would say almost immediately, because again, we select the best donors for this operation. The majority of these donors are young, who unfortunately might have died in a motor vehicle crash. And they're healthy.

That's why I would say close to 100% of these pancreases work right away.

Host Amber Smith: And what is recovery like after the surgery, for the recipient?

Reza Saidi, MD: The recovery is pretty much like a kidney transplant. The majority of these patients stay in the hospital maybe between five to seven days. And usually the full recovery takes about four to six weeks. And after that, the patient actually is back to normal, and again, won't require any insulin treatment. And because of that, these patients actually live longer compared to the patients that are on insulin treatment, insulin therapy, because insulin therapy is like a maintenance therapy. It doesn't cure the diabetes, but this pancreas transplant can cure diabetes.

Host Amber Smith: And so having a new pancreas, in terms of diabetes, if it cures the diabetes, does it also improve a person's overall health?

Reza Saidi, MD: Yes, absolutely. Actually, people have studied this because there are a lot of secondary complications of diabetes, like heart disease, peripheral vascular disease, eye disease, damage to the nerves, and people show that over time all those damages can be reversed.

That's why these patients actually live longer, because you cure the diabetes, and they can cause regression of secondary complications of diabetes.

Host Amber Smith: Now, I'm curious about what life is like for someone who has a pancreas transplant, because I've always heard that transplant recipients are taking immunosuppressant medicines for the rest of their life (to prevent their body's rejection of the transplanted organ).

Is that still true?

Reza Saidi, MD: That's correct. But now we have new medication with less side effects, safer, I think that that's why the majority of our patients, I feel more than 80% of these patients, go back to normal life and have no problem. But some of these patients, because of immunosuppression, can have some side effects, like develop a neuropathy (nerve damage) or develop, for example, cardiovascular disease or cancer.

But the majority of these patients actually do fine and tolerate the immunosuppression in the long term perfectly OK.

Host Amber Smith: Does having a pancreas transplant disqualify someone if they need a kidney transplant in the future?

Reza Saidi, MD: No, it doesn't.

Host Amber Smith: Now, if someone is listening who's got diabetes, and they're curious about whether they might be a candidate for a pancreas transplant, is this something that you find generally primary care providers are aware of?

Reza Saidi, MD: Primary care and endocrinologists, they should be aware of this. And that's why we try to get this message to the public and also to the primary care physician and endocrinologist. for a select group of patients, that might be the option. If they have the patients who have a difficult time to manage diabetes, or they get a lot of hypoglycemia, I think that pancreas transplant alone is a viable option for those patients. And at Upstate we're happy to see the patients and evaluate them and see if they're a candidate for pancreas transplant alone.

Host Amber Smith: What is the waiting list like for pancreas transplants?

Reza Saidi, MD: Actually, it's not very long. It's a small list because, as I said, for pancreas transplant alone it's a very selective group of patients. In the U.S., roughly 150 or 200 of these cases are done, because the managing of diabetes is getting better and better, but it's a very selective group of patients. If they cannot manage a patient effectively, this could be a viable option, with the current data showing that the outcome is getting better and better. And I think it's worthwhile to explore that option.

Host Amber Smith: Well, Dr. Saidi, thank you so much for taking time to tell us about this. I appreciate it.

Reza Saidi, MD: Thank you. Glad to be here.

Host Amber Smith: My guest has been transplant surgeon Reza Saidi. He's chief of transplant surgery at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.